What are the treatment guidelines for seborrheic keratosis?

Treatment Guidelines for Seborrheic Keratosis

Seborrheic keratosis (SK) lesions are biologically benign and do not require removal for medical reasons unless histologic confirmation is needed or the lesions become symptomatic, with cryosurgery being the most common and effective removal method. 1

Diagnosis and Clinical Assessment

• SK is the most common benign epidermal tumor in clinical dermatology practice 2
• Typically appears on the face and upper trunk, but can occur anywhere except palms and soles 2
• Diagnosis is usually made clinically, sometimes supplemented by dermoscopy 2
• Important to differentiate from actinic keratosis (AK), which has malignant potential 3

Treatment Indications

Treatment is primarily indicated for:

• Cosmetic concerns (most common reason) 1
• Symptomatic lesions (irritation, itching, bleeding) 1
• Diagnostic uncertainty requiring histologic confirmation 1
• Traumatized lesions 1

Treatment Options

First-Line Treatments

1. Cryosurgery

   • Most commonly used method 1
   • Advantages: Quick, office-based procedure
   • Limitations: May cause hypopigmentation, especially in darker skin types

2. Shave Excision

   • Provides tissue for histopathologic examination
   • Allows for more complete removal
   • Risk of scarring or pigmentary changes

3. Electrodessication

   • Effective for smaller lesions
   • Can be combined with curettage

4. Curettage

   • Often combined with electrodessication
   • Useful for raised lesions

Alternative Approaches

• Laser Therapy

  • CO2 or erbium:YAG lasers can be effective
  • May offer better cosmetic results in selected cases 2

• Topical Treatments

  • Currently an area of unmet need with no established effective topical agent 1
  • Experimental treatments combining antioxidants, keratolytics (urea, salicylic acid), and hydrating agents have shown promise in small studies 4

Special Considerations

Patient Selection

• Careful patient selection is required to optimize cosmetic results, particularly in:
  • Skin of color patients
  • Patients with thick lesions
  • Patients with numerous lesions 1

Dermoscopic Patterns

• SK can present with various dermoscopic patterns that may mimic malignant lesions
• Biopsy is mandatory for lesions that cannot be clearly differentiated from skin malignancies 5

Treatment Failures

• If a presumed SK fails to respond to treatment, consider:
  • Re-evaluation of diagnosis
  • Biopsy to rule out malignancy 3

Follow-up Recommendations

• No specific follow-up is required for treated SK lesions unless:
  • There are concerns about incomplete removal
  • The histopathology reveals unexpected findings
  • The patient develops new symptomatic lesions

Common Pitfalls and Caveats

1. Misdiagnosis: SK can mimic melanoma, basal cell carcinoma, or squamous cell carcinoma. When in doubt, perform a biopsy 5

2. Overtreatment: Remember that SK is benign and treatment is primarily for cosmetic or symptomatic relief 1

3. Sign of Leser-Trélat: Sudden appearance of multiple SKs can rarely be a paraneoplastic sign. Consider internal malignancy evaluation in these cases

4. Treatment Complications: Be aware of potential scarring, pigmentary changes, or infection following removal procedures

5. Patient Expectations: Clearly communicate expected outcomes and potential side effects before treatment to ensure patient satisfaction 6